Analysis of Vastus Lateralis and Vastus Medialis Activities in Men the Late Post-Surgery Period after ACL Reconstruction with LARS Synthetic Ligament

Background. The aim of the study was to assess the activity of the vastus lateralis (VAL) and vastus medialis (VAM) within 3-5 years after anterior cruciate ligament (ACL) reconstruction with a LARS synthetic ligament (the Ligament Advanced Reinforcement System) compared to muscle activity in the non-operated limb and in the limbs of the controls during selected functional tests. Material and methods. 20 men after ACL reconstruction using LARS synthetic ligament were qualified to the study group. The control group included 20 healthy men. Lysholm scale used to assess the functionality of the knee joint. To test muscle activity, TELEMYO DTS surface electromyography (sEMG) recording kit by Noraxon was used. The examined muscles on both limbs were the VAL and the VAM. The subjects were asked to perform the test-movements (dynamic ascent and descent from 25 cm step and slowly squats). Results. Statistically significant differences were noted only for the values of VAL SA_SD (the quotients of mean sEMG values of the VAL muscle during step ascent - SA and descent -SD; Z=2.83; p=0.0047) and VAM SA_SD (Z=1.98; p=0.0401) parameters. In each analyzed parameter higher values were recorded among people from the control group. Weak but significant correlations were found between the VAL and VAM: SA_SD and the results obtained on the Lysholm Scale. Conclusions. 1. In the group of patients after LARS, quadriceps activity disorders persisted in tested dynamic activities. 2. In the therapy planning or sports training in the distant period after ACL reconstruction with LARS, emphasis should be placed on quadriceps muscle training, and the sEMG test may be helpful in optimizing the management strategy.

Recurrent acromioclavicular joint dislocation with an associated coracoid fracture following acromioclavicular joint reconstruction

Acromioclavicular joint injuries are common and account for up to 12% of all shoulder girdle injuries and have been reported as being as high as 50% in sports-related shoulder injuries. While the majority of acromioclavicular joint dislocations can be treated non-operatively, there are certain injury configurations, which can include high-grade dislocations in overhead athletes, where surgery may be indicated. The surgical management of acromioclavicular joint instability has moved towards recreating the action of the coracoclavicular ligaments by resuspending the clavicle on to the coracoid. Multiple techniques using high-strength sutures, synthetic ligaments, tendon allografts or autografts passed either around or through the coracoid process have been described. However, an unusual, but significant, complication associated with these techniques is an iatrogenic fracture of the coracoid process. We report the case of a patient with an iatrogenic coracoid fracture following two failed acromioclavicular joint resuspensory reconstructions using a synthetic ligament. This injury was successfully treated with an autologous hamstring graft reconstruction, initially protected with a hook plate.

Comparative Study of Spring Ligament Reconstructions Using Either Hamstring Allograft or Synthetic Ligament Augmentation

Background: Idiopathic flatfeet are usually caused by attenuation of the medial soft tissues rather than a lateral osseous deficiency. Debate continues on whether spring ligament attenuation or posterior tibial tendon (PTT) dysfunction is the initial driver for the deformity. Our comparative prospective study aimed to quantify the radiological and clinical outcomes of 2 techniques for spring ligament reconstruction using a hamstring graft or a synthetic ligament. Methods: Seventeen spring ligament reconstructions (SLRs) were performed in 17 patients using synthetic ligament augmentation and 16 SLRs were performed using hamstring allograft in 13 patients. Additional procedures such as gastrocnemius recession, PTT advancement, flexor digitorum longus transfer, and calcaneal osteotomy were performed as required. A minimum of 12 months of follow-up was available for all cases. Radiographic analysis was performed with standardized parameters. Results: Following SLR with synthetic ligament augmentation, all radiological parameters significantly improved ( P < .05). Hamstring allograft SLR also demonstrated significantly improved radiographic parameters in all but Meary’s line at final follow-up. At 12 months, patient outcome scores were significantly better in the synthetic ligament group. Conclusion: Reconstruction of the spring ligament using either hamstring allograft or synthetic ligament augmentation provided significant improvements in radiological alignment; however, superior patient-reported outcomes were found in the synthetic ligament augmentation group. Levels of Evidence: Level III, retrospective cohort study.

The Experience of ACL Reconstruction with Synthetics Ligament: Where are we now?

The dispute on artificial ligaments used for anterior cruciate ligament (ACL) reconstruction has been a long time issue. Admittedly, due to designing defects, materials deficient without creeping, viscoelasticity and biocompatibility, and incorrect surgical technique, early application of synthetic ligament in ACL reconstruction did not yield good outcomes. For a long time, a poor outcome occupied our consensus. Whilst the poignant lessons didn’t drive people to thoroughly figure out underlying reasons but amplified the fear of synthetics ligament in the ACL reconstruction. Recent 15 years, a new generation synthetic ligament, Ligament Advanced Reinforcement System (LARS) developed for ACL/PCL reconstruction has been widely used in China. There are at least 147 papers on LARS published in Chinese and over 47 SCI papers published in English. Consistently, a positive outcome has been concluded in most reports with an early return to sports and lower complication or failure rate. Cumulative failure rate from short- and mid-term follow-ups was only 2.6% according to Batty et al., which has been commended as “surprisingly impressive” by James H. Lubowitz of journal Arthroscopy. In China, LARS ligaments have been approved by CFDA since 2004 and been used for ACL reconstruction over 30,000 cases. Recently a national multi-centers clinical investigation has been done in long-term failure analysis of the ACLR with LARS, which has involved 20 Chinese clinical centers and 1146 cases with mean follow-up time of 87 months（7 years）, organized by the Chinese Artificial Ligament Study Group (CALSG), with an acceptable outcome in failure rate of 4.5% and complication rate of 4.1%. The following factors were concluded as main failure reasons, 1）incorrect surgical technique in a non-isometric ACL reconstruction, 2）lack of the graft biocompatibility and rigid screw interface fixation, 3) non-suitable indicated patients’ selection and rehabilitation program. Compared with reported long-term failure rate in auto（10%）or in allografts（24%）, the outcome of Synthetic ligament was more superior and acceptable results. Moreover, the functional evaluation and return to sports of the patients were also high satisfying, despite some complication, such as screw loose, remnant stimulation but very rear synovitis. Non-isometric tunnel position was the main failure reason which caused by surgeons tech. An ISOMETRIC surgical technique should be stressed especially in ACL reconstruction using synthetic, focused on surgeon education, instead of simply blaming the artificial graft. Based on the systemic review and our study, a modification of synthetic graft has been developed successfully in experiment, graft fixation, synthetics materials modified with Polyethylene Terephthalate (PET) which has facilitated the biocompatibility. Our clinical investigation has also focused on a near-isometric ACL reconstruction, which would decrease the graft tunnel motion and facilitate artificial graft successful. Non-isometric input will predispose the grafts easy failure because of over tension on the graft while joint moving. Carefully selected patients, proper surgical technique, and standard rehabilitation program will ensure artificial ligament successfully. We will keep devoting to innovate artificial ligaments, including tissue engineering, bio-mimics design, advanced fixation, hybrid graft designing and more precise Isometric surgical technique. Never forgetting our beginning mind, the artificial ligaments will open a new epoch in the future of ACL reconstruction.

Early Outcomes of Pes Planus Reconstruction Using Either Hamstring Allograft or Synthetic Ligament

Category: Hindfoot, Midfoot/Forefoot Introduction/Purpose: Maintenance of the medial longitudinal arch is crucial to efficient kinematics in gait. It is supported by as complex interplay of osseous structures, ligaments, extrinsic tendons and plantar fascia. Two ligaments critical to stabilising the medial longitudinal arch are the Spring (Calcaneofibular) and Naviculocuneiform ligaments. The Spring Ligament serves as a sling within the “Acetabulum Pedis” to orientate the Talus relative to the Calcaneus and Navicular. The Naviculocuneiform ligament is an important plantar tension band and a separate entity to the Posterior Tibial Tendon (PTT) insertion. Attenuation of these ligaments leads to Pes Planus deformity and subsequent defunctioning of the PTT. This study evaluates the functional and radiological outcomes of Spring and Naviculocuneiform ligament reconstruction using Hamstring (Semitendinosis) Allograft and Synthetic ligament (Internal BraceTM, Arthrex). Methods: 33 consecutive Pes Planus reconstructions were performed between 11/11/2013 and 06/03/2018. All patients were followed up prospectively with serial radiographs and functional scores including; MOXFQ, EQF5D and VAS. Minimum follow up was six months. At the midpoint during the study there was transition to using Synthetic Ligament instead of allograft. This was due to availability and ease of use. Surgical technique for both reconstructions included a proximal medial gastrocnemius recession and medialising calcaneal osteotomy. For allograft reconstructions, a pre-tensioned Semitendinosis allograft was fixed proximally to Talar neck using a tenodesis screw and passed plantar to PTT and through a bone tunnel in the medial cuneiform. Synthetic ligaments were inserted from the Sustentaculum Tali to the medial cuneiform in a hammock fashion. In both reconstructions tendinopathic PTTs were excised and a Flexor Digitorum Longus transfer used. Results: There were 17 synthetic ligament reconstructions (6 male, 11 female) and 16 allograft reconstructions (6 male, 10 female). Groups were matched pre-operatively for age, functional scores and radiological markers (T test P values >0.05). At six months significantly better improvements were observed in the synthetic ligament group compared to allograft group with regards to VAS, MOXFQ pain score, Meary’s line, 1st metatarsal Talus angle, Talonavicular uncoverage angle and Hindfoot alignment (T test P < 0.05). Statistical significance was maintained at 12 months with the synthetic ligament providing a significantly better reduction of Meary’s line 1st Metatarsal Talar angle, Talonavicular uncoverage and hindfoot alignment. 2 patients were revised to double fusions in the allograft group and 1 patient revised in the synthetic ligament group. Conclusion: Statistically significant improved functional scores and radiological appearance can be found up to 1 year following Synthetic ligament reconstruction of the Spring and Naviculocuneiform ligaments when compared to Hamstring allograft.

Traumatic Patellar Tendon Rupture Repair Using Synthetic Ligament Augmentation

Rupture of the patellar tendon is an infrequent pathology, and surgical repair with nonabsorbable sutures is the gold standard for management. Many surgeons augment the repair using one of many proposed methods: cerclage wires, Dall–Miles cables, autologous hamstring grafts, and tendon allografts. In this study, we propose the augmentation of patellar tendon repair using an artificial ligament. The questions to be assessed in this study are as follows: (1) measurement of functional results 1 year after surgery using the Lysholm score and (2) the incidence of both rerupture, and surgical complications within the first year postsurgery, the median knee range of motion at 3 months and 1-year postsurgery, patient satisfaction, and postsurgery patellar height, measured using the Caton–Deschamps Index. In our center, we performed 30 suture repairs of traumatic patellar tendon ruptures between 2015 and 2016. Tendon repair was always augmented using an artificial ligament (LT60, Orthomed). The results were evaluated 1 year after surgery. The 1-year postsurgery median Lysholm score was 96 (first quartile–third quartile [Q1–Q3]: 95–100). None of the following complications were reported: second surgery for any reason, new rupture, and superficial or deep infection. Radiological analysis showed a median Caton Index of 1 (Q1–Q3: 0.9–1) postsurgery. Excellent Lysholm scores were observed 1 year after synthetic ligament augmentation of patellar tendon sutures, with a low rate of complications compared with published studies.